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PubMed1987

Early repair and breast-feeding for infants with cleft lip.

This study attempts to define the effect of early repair and breast-feeding on the outcome of cleft lip surgery. The first part deals with 100 consecutive cleft lip repairs categorized retrospectively by age at operation. Forty-nine patients were operated on during the first 3 weeks of life; 51 at an older age. There were no statistically significant differences in complication rate between the groups (14 and 18 percent, respectively). A subgroup of 26 infants was operated on at a week or less of age; these sustained significantly fewer complications (8 percent). There was no apparent difference in the operative results as defined by whether or not the child needed a subsequent revision. A second group of 60 mothers was offered the choice of breast-feeding their babies immediately following operation. Sixteen breast-fed for a minimum of 6 weeks, 22 were fed by means of a cup or syringe, and 22 started breast-feeding but converted to a bottle within 6 weeks. No complications attributable to breastfeeding were observed, and the rate of weight gain was definitely enhanced in the breast-feeding group. Hospital stay was shortened by an average of over a day (33 percent) as compared with those fed by cup. This effect was related to the easier transition from IV administration to oral intake when breast-fed. We are currently encouraging early repair and breast-feeding in the full-term baby as the optimum method of management of newborns with cleft lip.

Body Weight↗
PubMed1987

Primary repair of the unilateral cleft lip nose in the Oriental: a 20-year follow-up.

The unilateral cleft lip nasal deformity is corrected as a primary procedure with the lip repair. The abnormal attachment of the alar base is first released by an incision along the superior buccal sulcus and piriform margin. There is no intercartilaginous incision. Basically, we use the Brown-McDowell technique with the addition of an alar rim incision. Undermining of the ala between the two incisions is carefully and adequately done, splitting it into two layers. The first is a skin and the second, a chondrocutaneous (vestibular skin) layer, which is handled as a single unit, thus enhancing its vascularity. This second layer is a bipedicle flap with a broad medial pedicle and a narrow lateral pedicle at the alar base. When the alar base is rolled into its normal position, the chondrocutaneous unit hinging on its two pedicles counterrotates, correcting the subluxation of the ala, a major component of the cleft lip nasal deformity. We depend on the normal position of the alar base, the postoperative scar tissue, and the inherently thick nostril wall in the Oriental to keep the alar dome up. No transfixion sutures are used. Ten consecutive patients are shown 20 years after surgery. All had one operation only. None showed any disturbance of nasal growth.

Adult↗
PubMed1989

Repair of cleft lip with nonsurgical correction of nasal deformity in the early neonatal period.

Auricular cartilage is soft and plastic at birth, so that congenital auricular deformities can easily be corrected nonsurgically in the early neonatal period. However, as the infant grows older, the flexibility of the auricle decreases. Alar cartilage exhibits the same elasticity as auricular cartilage in the early neonate. When a cleft lip is repaired, typically when the infant is about 3 months of age, it becomes difficult to correct the nasal deformity without surgical intervention. However, based on our experience, there is a fair possibility of correcting the cleft lip nasal deformity with a nonsurgical procedure in the early neonatal period. We performed cleft lip repair accompanied by nonsurgical correction of the nasal deformity in 44 neonates aged 2 to 7 days. A special retainer was placed in the affected nostril for 3 months. Following observation of 31 infants for 12 months or longer, their nasal shapes and symmetry were considered superior to those conventionally operated on at about 3 months of age. Except for one nasal infection, there were no complications.

Cartilage↗
PubMed1991

Pathophysiology of cleft lip muscles following the initial surgical repair.

Muscle biopsy specimens taken from the upper lip and perialar area during the time of secondary lip revision and studied by histochemical techniques demonstrate persistent connective-tissue and muscle abnormalities even at a distance from the cleft margins. Some of these changes are consistent with surgically induced denervation-reinnervation of muscle groups in the surgical field. Increased amounts of connective tissue also were found, most likely secondary to the original deformity and the subsequent surgical procedures. Both these changes may be important factors in subsequent abnormal growth and development of the underlying midfacial structures. This study also demonstrated the resolution of previously noted mitochondrial abnormalities found in the primary cleft lip patient.

Adolescent↗
PubMed1998

A comparative study of the lateral crus of alar cartilages in unilateral cleft lip nasal deformity.

To confirm whether or not the alar cartilage of the unilateral cleft lip nose is primarily hypoplastic as compared with the noncleft side, 35 unilateral cleft lip nasal patients who had no previous nasal surgery underwent direct measurement of the lateral crus of alar cartilage on both sides during their nasal tip plasties. Both lower lateral cartilages were dissected freely, and the thickness was measured at the intercrural, middle, and distal portions. The width was measured at the widest portion, and the length was measured from the intercrural point to the distal end. Two-mm-punch biopsies were obtained from each cartilage for histologic study. The lateral crus of the cleft side was no smaller than that of the noncleft side. Histologically, no difference was ascertained. In conclusion, we think the lateral crus of the alar cartilage of the cleft side is not hypoplastic. Therefore, external factors such as soft-tissue defect or external abnormal vector force are more attributable than intrinsic factors to the development of cleft lip nasal deformity.

Adolescent↗
PubMed1998

Mitochondrial activity of orbicularis oris muscle in unilateral cleft lip patients.

To better evaluate the role of a possible mitochondrial alteration in the pathogenesis of cleft lip, we obtained and examined 38 orbicularis oris muscle specimens taken from the cleft margin of both cleft and noncleft sides of 10 unilateral cleft lip infants at the time of primary closure. Part of each sample was frozen in liquid nitrogen/cooled isopentane, while the remainder was fixed in 2.5% glutaraldehyde, postfixed in osmium tetroxide, and embedded in Araldyte resin. Ten-micrometer-thick sections were obtained from the frozen samples and stained for histologic (Gomori trichrome) and histochemical (adenosine triphosphatase, nicotinamide adenine dinucleotide-tetrazolium reductase, cytochrome c-oxidase, succinate dehydrogenase) techniques. Ultra-thin sections (70 to 100 nm) of the resin-embedded specimens were stained with uranyl acetate and lead cytrate and were examined with a Zeiss 109 transmission electron microscope operating at 80 kV. Muscular fiber-type ratio was found to be 19.2 percent type 1 and 80.8 percent type 2 fibers on the cleft side and 26.3 percent type 1 and 73.7 percent type 2 fibers on the noncleft side. We detected aspecific structural alterations, such as variations in the fiber size without fiber group atrophy or fiber-type grouping with the ATPase reaction, in all biopsies. Although Gomori trichrome revealed a dark staining and red granularity of the fibers, suggesting an increase in mitochondria activity, no ragged-red fibers or cytochrome c-oxidase-negative/succinate dehydrogenase-positive fibers were found. At the ultrastructural level, the mitochondrial morphology was always preserved, without inclusions or variations in size and/or shape. On the other hand, we invariably noticed an increase of the number of mitochondria, associated with abnormal glycogen deposits, in some areas of every specimen. Both of these two latter findings were regularly localized at the periphery of the sarcolemma, resembling the so-called lobulated fibers, an aspecific sign of muscular flogosis. Our findings, although excluding an inherent metabolic myopathy of orbicularis oris muscle in unilateral cleft lip patients, evinced both an increased oxidative metabolism and a generic inflammatory condition of that muscle, the nature of which must still be defined.

Adenosine Triphosphatases↗
PubMed1998

Photogrammetric comparison of two methods for synchronous repair of bilateral cleft lip and nasal deformity.

The principle of synchronous repair of bilateral complete cleft lip and nasal deformity is established, and the techniques are evolving. We undertook photogrammetric comparison of the method described by Mulliken (group I, n = 15) and that described by Trott (group II, n = 10). Facial proportions and angles were measured on preoperative and postoperative photographs using defined anthropometric points. The following criteria were quantified for each test group: nasolabial angle, nasal tip angle and projection, nasal width, columellar length and width, and philtral width. All parameters in both groups were compared against each other and against normal age-matched values. Results were analyzed by t test. The nasolabial angle, nasal tip angle, and nasal width were abnormally wide for both techniques (p < 0.01 for both), and there was no difference between them. Nasal tip projection was greater than normal in both techniques (p < 0.01); group I had significantly greater projection than group II (p = 0.02). Columellar length as a proportion of nasal tip protrusion approached normal in group I but was significantly shorter than normal in group II (p < 0.001). Columellar width, as a proportion of nasal width, was normal for both groups. Philtral width, in proportion to nasal width, was normal in group I and abnormally high in group II (p < 0.001). This difference was significant between the two groups (p < 0.001). In a separate cohort of 10 group I patients, the nasolabial angle was measured on lateral photographs taken 1 year post-repair and at intervals to late childhood and adolescence. Nasolabial angle changed with age from obtuse to normal in 7 of 10 patients followed to 9 years of age and in 5 of 6 patients followed until age 15 years. Columellar and upper labial inclination to the vertical were measured in 7 of these patients at 3 to 4 years and again at 13 to 15 years. There was an increase in inclination of both columella and the upper lip, between the ages of 3 to 4 and 13 to 15 years, reflecting improved lip support and growth of septum and lateral cartilages.

Child↗
PubMed1999

Fetal unilateral cleft lip and palate: detection of enzymic anomalies in the amniotic fluid.

Aims of this study were to evaluate whether it is possible to determine, by means of isoelectric focusing, an enzymic differentiation in human amniotic fluid, and whether the onset of fetal cleft lip and palate is accompanied by a pathologic enzymatic differentiation pattern in amniotic fluid. From January of 1993 to June of 1996, amniotic fluid samples from 315 healthy pregnant women (ages 22 to 43 years, mean 37 years; gestational age 14 to 22 weeks, mean 17 weeks) were examined. The normality of all pregnancies was confirmed at birth. Moreover, amniotic fluid samples were examined from three pregnancies (ages 36, 35, and 30 years; gestational ages 16, 18, 24 weeks) with fetal unilateral cleft lip and palate (confirmed at birth), diagnosed by ultrasound. The authors have tested as "metabolic" markers the enzymes lactate dehydrogenase and creatine phosphokinase. For the concentration rates of both the tested enzymes, a statistically significant difference (p = 0.003) was found between amniotic fluid samples obtained from normal and affected pregnancies. These data, in the authors' opinion, corroborate the hypothesis that a local metabolic impairment is somehow involved in the pathogenesis of cleft lip and palate.

Adult↗
PubMed1999

Three-dimensional computed tomographic analysis of the primary nasal deformity in 3-month-old infants with complete unilateral cleft lip and palate.

The purpose of this study was to analyze the geometry of the primary cleft lip nasal deformity using three-dimensional computerized tomography in a group of 3-month-old infants with complete unilateral cleft lip and palate before surgical intervention. Coordinates and axes were reconfigured after the three-dimensional image was oriented into neutral position (Frankfurt horizontal, true anteroposterior, and vertical midline). Display and measurement of skin surface and osseous tissues were achieved by adjusting the computed tomographic thresholds. S-N, N-ANS, S-N-O, and S-N-ANS were measured from true lateral views. Biorbital (LO-LO), interorbital (MO-MO), intercanthal (en-en), and nasal (al-al) widths were measured from the anteroposterior view. The bony alveolar cleft width was measured from the inferior view. The study group was divided into two groups on the basis of skeletal alveolar cleft width: six patients with clefts narrower than 10 mm and six patients with clefts wider than 10 mm. Only the S-N-ANS angle differed between the two groups, i.e., it was greater in the group with the wider clefts (p < 0.05). Coordinates of six landmarks at the base of the nose [sellion (se), subnasale (sn), cleft-side and noncleft-side subalare (sbal-cl and sbal-ncl), and the most posterior point on the lateral piriform margins (PPA-CL and PPA-NCL)] were obtained for analysis of the nasal deformity. On average, the subnasale point was anterior to sellion and deviated to the noncleft side; the cleft-side sbal point was more medial, posterior, and inferior than the noncleft-side sbal point; and the PPA point on the cleft-side piriform margin was more lateral, posterior, and inferior than the PPA point on the noncleft side. These discrepancies were not universally observed. However, in all patients, four findings were observed without exception (p < 0.01): (1) subnasale (sn) was deviated to the noncleft side (mean distance from midline, 5.0 mm; range, 2 to 9.5 mm), (2) the cleft-side alar base (sbal-cl) was more posterior than the noncleft-side alar base (sbal-ncl) (mean difference, 3.6 mm; range, 1 to 5.5 mm), (3) the noncleft-side alar base (sbal-ncl) was further from the midline than the cleft-side alar base (sbal-cl) (mean difference in lateral distances of sbal-ncl and sbal-cl from the midline, 2.8 mm; range, 0.5 to 7 mm), and (4) the cleft-side piriform margin (PPA-CL) was more posterior than the noncleft side piriform margin (PPA-NCL) (mean difference, 2.1 mm; range, 0.5 to 4 mm). In conclusion, the nasal deformity in unilateral cleft lip and palate that has not been operated on is characterized by these four features and increased S-N-ANS angle with increased alveolar cleft width.

Cephalometry↗
PubMed2000

Creating long-term benefits in cleft lip and palate volunteer missions.

The authors present their experience with 15 years of organizing cleft lip and palate surgical volunteer missions in Latin America. The history, basic principles, and objectives of Operation San Jose, a volunteer goodwill program from Christus St. Joseph Hospital in Houston, Texas, are covered. This report addresses the different problems encountered and solutions found. Following the principles set by Operation San Jose, CIRPLAST is a Peruvian foundation for plastic surgery that travels to remote areas in Peru, operating on patients with cleft lip and palate deformities. This report highlights the importance of working with local plastic surgeons and their residents, and emphasizes that the program should be organized by and the operations performed by accredited plastic surgeons and with the auspices and support of the national plastic surgery society and the local medical board. Operation San Jose promotes the creation of long-term benefits by offering a program to teach local surgeons cleft lip and palate repair techniques and to set up guidelines to organize local surgeons so that they can continue this effort by treating their own patients in their own countries.

Child↗
PubMed2000

Early results of vermilion lip augmentation using acellular allogeneic dermis: an adjunct in facial rejuvenation.

The definitive approach to lip augmentation has yet to be defined. Herein is described a technique using acellular allogeneic dermal grafts that is easy, effective, and reproducible. Our results over the past 2 years include 47 patients (94 grafts). Three grafts to the upper lip have exhibited significant resorption, which warranted further augmentation. Early in the series, one graft was malpositioned too superiorly along the vermilion-cutaneous border. There have been no cases of infection, hematoma, or graft exposure. The overall complication rate was 4 percent (4 of 94). Our early results by using acellular allogeneic dermal grafts for lip augmentation are encouraging. Further studies are under way to better objectively define long-term results.

Adult↗
PubMed2000

Cleft lip: unilateral primary deformities.

The understanding and management of all aspects of unilateral cleft lip deformities continue to evolve. Just as we are entering the era of exciting advances in the understanding of the pathogenesis of craniofacial disorders, expansion of our understanding of the dynamic relationships of the structural and soft-tissue components of cleft deformities has assisted surgeons in achieving progressively improved and consistent outcomes for these patients. The anatomic and physiologic complexity of unilateral cleft lip deformities has been recognized for centuries, and generations of researchers have cumulatively contributed to our current understanding. This article examines the history, classification, anatomy, and controversies in the surgical management of unilateral cleft lip deformities, allowing surgeons to formulate a reasoned, longitudinal management plan for their patients on the basis of the available current data.

Child↗
PubMed2000

Long-term outcome of cleft lip nasal reconstruction in childhood.

This study documents the pattern of unilateral cleft lip nasal reconstruction in the practice of one surgeon at a tertiary cleft center, evaluating the long-term appearance outcome of single-operation unilateral cleft lip nasal reconstruction in childhood. A retrospective medical record review was performed for all patients with a diagnosis of unilateral cleft lip and age greater than 15 years. Operative notes were reviewed, recording 15 variables identifying specific rhinoplastic maneuvers. Nasal appearance outcome analysis was performed for all patients who underwent only one nasal surgery before 12 years of age (n = 19). Standard frontal whole face photographic images were presented as opposing pairs in a looseleaf binder to two panels, 1 of 10 lay persons and 1 of 10 plastic surgeons. Each pair consisted of photographs of the same patient at different ages in one of three combinations: preoperative-perioperative, perioperative-longest postoperative, or preoperative-longest postoperative. Participants were asked to compare the appearance of the noses in the two photographs and assign a rating based on a 5-point Likert scale. Statistical analyses were performed on the data collected in the aesthetic analysis. The effect of surgery upon nasal appearance was assessed by comparing the preoperative and perioperative photographs. The effect of growth was assessed by comparing the perioperative and long-term postoperative photographs. The combined effect of surgery and growth was assessed by comparing the preoperative and long-term postoperative photographs. The data were assessed by lay and professional evaluators, together and separately, to determine whether differences existed. The majority of patients did not undergo revisional nasal surgery, whereas those who did usually had one nasal operation. Most revisional nasal surgery was performed in conjunction with other cleft-related secondary surgery. A majority of lay and professional evaluators perceived revisional nasal surgery as improving nasal appearance in the short-term and to a lesser degree in the long-term, as compared with the preoperative state. Evaluations of revisional nasal surgery are generally constant between the short-term and long-term postoperative images. Lay evaluations may be contaminated by a general decline in attractiveness with aging. Patient preference should be a major factor in the decision for nasal revision surgery. Multiple means of assessing nasal appearance outcome need to be used to validate results. Nasal appearance outcomes need to be correlated with outcomes with respect to nasal morphology and function as well as patient and parent satisfaction.

Adolescent↗
PubMed2001

Repair of bilateral complete cleft lip: intraoperative nasolabial anthropometry.

Synchronous repair of bilateral complete cleft lip and nasal deformity requires conception of three-dimensional form and fourth-dimensional changes with growth, as distorted by the malformation. The aim is to obviate typical postoperative nasolabial stigmata. The strategy is to construct fast-growing features on a smaller scale and slow-growing features on a normal or slightly larger scale. In this study, intraoperative alterations in nasolabial dimensions were documented by anthropometry in 46 consecutive infants with bilateral complete cleft lip. These values were averaged and compared with measures from normal Caucasian infants at ages 0 to 5 months and 6 to 12 months. Nasal height (n-sn) and nasal width (al-al), both fast-growing features, were set smaller (88 percent and 96 percent, respectively) than those of age-matched normal infants. In contrast, the slow-growing features, nasal protrusion (sn-prn) and columellar length, were constructed longer than normal (130 percent and 167 percent, respectively). Because all labial features grow rapidly, they were made diminutive in this study, with the exception of central vermilion-mucosal height (median tubercle), which was purposively made full. These maneuvers resulted in a normal, average overall upper-lip height (sn-sto). Two technical refinements also are described: (1) construction of deepithelialized bands flanking the philtral flap to improve surface contour; and (2) positioning and fixation of the dislocated alar cartilages, performed entirely through superiomedial nostril rim incisions.

Cephalometry↗
PubMed2002

Anatomy of the nasal cartilages of the unilateral complete cleft lip nose.

The purpose of this study was to disclose the relationship between the anomaly of the cartilaginous framework and the nasal deformity of cleft lip. The noses of six stillborn infants with unilateral complete cleft lip were carefully dissected. The size and weight of the lower lateral cartilages were measured to determine whether there was a significant difference between the normal and involved sides. The position of the nasal cartilages was observed, and the distance between them was measured to determine whether they were normal. The surgical dissection revealed that the lower lateral cartilages from both sides were asymmetrical in three dimensions, indicating the displacement of the lower lateral cartilage on the involved side. There was displacement of the cartilaginous septum and the upper lateral cartilage. The statistical evaluation did not demonstrate a significant difference between weight and size of the two sides. One of the major causative factors of nasal deformity is displacement of the nasal cartilages. There is no hypoplasia of nasal cartilage in newborn infants with cleft lip.

Cleft Lip↗
PubMed2002

Resorbable internal splint: an adjunct to primary correction of unilateral cleft lip-nasal deformity.

There is usually some relapse in position of the alar cartilage after primary repair of unilateral cleft lip. Therefore, preoperative or postoperative external splinting has been recommended to supplement either closed or open suspension of the alar cartilage. The authors present a method using a resorbable internal nostril splint to shield the positioned alar cartilage from deformational forces caused by scar, and thus avoiding the problems associated with external splinting. An internal nasal splint was placed in 15 infants during repair of unilateral complete cleft lip and nasal deformity. The nasal morphology was compared with that of 15 control patients who had the same nasolabial procedure without internal splinting. Average follow-up time was 20.4 months (range, 4 to 30 months). Photogrammetric analysis showed that asymmetry of the alar contours averaged 8.6 percent in the splinted patients, as compared with 23 percent for controls (p <0.01). Thus, alar asymmetry was decreased two-thirds in the splinted group. An internal resorbable nasal splint is an adjunct to open alar suspension in primary repair of the unilateral cleft lip nasal deformity. An internal nasal splint protects the corrected alar cartilage longer than an external splint and eliminates drawbacks, such as necrosis, cutaneous depression of the nostril sill, and patient noncompliance. This strategy of temporary internal support of healing cartilage has other applications.

Absorbable Implants↗
PubMed2003

Positive effects of mime therapy on sequelae of facial paralysis: stiffness, lip mobility, and social and physical aspects of facial disability.

OBJECTIVE: Evaluation of the effect of mime therapy, a novel therapy combining mime and physiotherapy, for patients with longstanding (at least 9 months) sequelae of unilateral peripheral facial paralysis. STUDY DESIGN: Randomized clinical trial, with the treatment group receiving mime therapy and the control group forming a waiting list. SETTING: Physiotherapy outpatient department of two university medical centers. PATIENTS: There were 50 patients, 21 men and 29 women, with sequelae of facial paralysis and a mean House-Brackmann score of Grade IV. INTERVENTION: Mime therapy, including automassage, relaxation exercises, inhibition of synkinesis, coordination exercises, and emotional expression exercises. MAIN OUTCOME MEASURES: Stiffness of the face, lip mobility (both lip and pout length) and the physical and social index of the Facial Disability Index. RESULTS: Stiffness, lip mobility, and both aspects of the Facial Disability Index improved substantially because of mime therapy. CONCLUSIONS: On the basis of present evidence, mime therapy is a good treatment choice for patients with sequelae of facial paralysis.

Adult↗
PubMed2003

Risk factors for poor dental arch relationships in young children born with unilateral cleft lip and palate.

To identify risk factors for poor dental arch relationships in children with unilateral cleft lip and palate in the United Kingdom, the authors performed a cross-sectional outcome study with retrospective data capture of treatment histories in children under the care of 44 cleft teams in the United Kingdom. The study sample comprised 238 children born with nonsyndromic complete unilateral cleft lip and palate between April 1, 1989, and March 31, 1991, who were between 5.0 and 7.7 years of age (mean age, 6.5 years) at the time of data collection. The Five-Year-Old Index was used to rank dental arch relationships from dental study models. Velopharyngeal insufficiency was assessed with the use of the Cleft Audit Protocol for Speech. An independent panel recorded surgical treatment histories from the clinical notes. There was no association between the technique and the timing of primary repair, the experience of the surgeon, or presurgical orthopedics and dental arch relationships. Secondary velopharyngeal surgery was independently associated with poor outcome (OR, 4.14; 95 percent CI, 1.6 to 10.7; p = 0.003). Primary nasal repair was protective (OR, 0.47; 95 percent CI, 0.23 to 0.93; p = 0.031) against poor dental arch relationships. Secondary velopharyngeal surgery and primary nasal repair were found to be independently associated with dental arch relationship outcomes in young children with unilateral cleft lip and palate in the United Kingdom.

Child↗